That is the most common expression I hear when I speak with someone who bought their family’s Healthplan online without the advice and counsel of an expert to explain all the benefits. Whether it is Group or Individual Insurance, most people think their health insurance works like car insurance. Satisfy the deductible, and the insurance takes care of the rest. Well, with one exception, it just does not work that way. Most companies, Blue Cross, Blue Shield, Aetna, HealthNet,  Pacificare, and even Kaiser have deductibles and then dreaded co-insurance up to an Out-of-Pocket Maximum (aka-Exposure).

To me, this Out-of-Pocket Maximum is the most important element to consider when purchasing Health Insurance. If you choose a common $2,500 deductible plan with $25-$30 Doctor co-pays and a Prescription Drug plan (neither of which are subject to the deductible), if you end up in the Hospital, or need an Out-patient surgery, you will pay not only the $2,500 deductible, but also 30%-50% of cost until you reach the Out-of-Pocket maximum. Most common this figure is between $5,000 and $7,500 on top of your deductible. Hello, that means on a $22,000 bill, you pay $7,500. A common shoulder or knee surgery and you are in the hole big-time, despite all the premiums you had been paying. I call this EXPOSURE. How much would you have to pay in total,  if something significant happened to you or your family? Relax, if you are already my client, we have you on the exception and you are not subjected to this EXPOSURE. If you know someone who has one of these companies plans, have them call for a consultation to see if we can improve this exposure structure for them. The plans have affordable deductibles, but then kick in and pay 100%. Your total deductible is your total exposure!

In group insurance, the Exposure might not be quite so high, but some plans get near $5-6,000, which can choke employees. So too, in group insurance, this Out-of-Pocket Maximum is often overlooked, but nonetheless, is a vital element that should be looked at in the decision process. We make sure our clients are aware and are managing this vital area. It is not OK for the broker to just say that they all do it and they are in the ballpark. For a no-obligation consultation on your plan, contact us at info@davidlindseyinsurance.com .